go back

Wyoming rates for HCPCS L0455

Thoracic-lumbar-sacral orthosis (TLSO), flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, off-the-shelf

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$96.42 / $96.42 / $217.85
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$167.16 / $167.16 / $167.16
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$167.16 / $167.16 / $167.16
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$278.10 / $278.10 / $372.96
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$203.01 / $203.01 / $278.10
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$175.30 / $186.23 / $206.76